Coronary Artery

Disease
(Ischemic Heart Disease)

Bernardo D. Morantte Jr. M.D.

Dept. of Medicine
College of Medicine
Pamantansan Ng Lungsod Ng
Maynila
 Anatomy of the Coronary
Arteries
Aorta LCA
LMCA Left anterior
descending
RCA
SA nodal
artery Circumflex
Diagonal
Septal Bx
RV branch perforator

Obtuse marginal
LV
branch Postero-lateral

Posterior descending
Posterior circumflex
branch
 Physiology of Coronary
Circulation
 Myocardial perfusion occurs mainly
in diastole BP 120/60
Epicardium
Epicardial artery

Subendocardium Intramural arteries

Endocardium

LV
LV pressure 120 /10

Diastolic pressure gradient = 50 mm HG

< 40 mm mean aortic pressure

coronary flow is zero.
 Regulation of coronary blood
flow
 Aortic driving pressure which is affected
by the presence stenosis in the coronary
arteries
 LVED pressure
 Heart rate and diastolic filling time
 Coronary vascular resistance _ from the
contraction and relaxation of the smooth
muscles
 Endothelium derived vasodilator
substance which is affected by the
presence of atherosclerosis
 Myocardial oxygen demand
 Types of Coronary artery
disease
I Congenital
 Anomalous origin from the
pulmonary
artery
 Anomalous origin from other
coronary
arteries
 Hypoplastic artery
 Myocardial bridging
 Coronary AV or sinus fistulas
 Anomalous Origin of the
Coronary
Aorta
Arteries
LCA Left anterior
LMCA descending
RCA
SA nodal
Circumflex
artery
Diagonal
Septal Bx
RV branch perforator

Obtuse marginal
LV
branch Postero-lateral

Posterior descending
Posterior circumflex
branch
 Types of coronary artery
diseases
Continued
II Atherosclerotic _ most common

III Non- atherosclerotic

 Embolus_ atrial fibrillation, endocarditis
post cardiac valve replacement,
atrial myxoma
 Drug induced ex. cocaine
 Vasculotides
 Kawasaki
 Aortic dissection
 Iatrogenic
 Atheroma

Foam cells
Macrophages
Plaque Smooth muscle
proliferation and
migration
Fibroblast
calcification

Cross section of an artery

 Myocardial Bridging
Left anterior
descending

Epicardium Intramyocardial segment

Endocardium

LV
 Aortic dissection
Aorta LCA
LMCA Left anterior
descending
RCA
SA nodal
artery Circumflex
Diagonal
Septal Bx
RV branch perforator

Obtuse marginal
LV
branch Postero-lateral

Posterior descending
Posterior circumflex
branch
 Myocardial ischemia
 Is
the imbalance between the oxygen
supply and the myocardial demand
for oxygen resulting in some
reversible cellular changes in the
sarcolema.
 Clinical Syndromes of CAD
 Classic angina is chest discomfort resulting from myocardial
ischemia due to coronary blood flow insufficiency, related to
physical exertion and relieved by rest, maybe associated with
transient ST depression in the EKG.

 Variant angina is chest discomfort characteristic of angina

occurring at rest associated with transient ST elevation in the EKG.

 Unstable angina_ new onset, prolonged chest pain (20- 30

mins), acceleration of angina, failure to respond to medical
therapy.

 Acute MI _ angina like chest discomfort lasting > than 30 mins.

associated with sustained EKG changes and enzymatic evidence of
myocardial necrosis

 Sudden death syndrome _ sudden cardiovascular collapse with

loss of blood pressure and heart beat.
 Clinical Syndromes of Coronary
artery disease (CAD)
Mechanism
Chronic stable > 50 % stenosis
(x-area)
 Angina Variant angina ( Prinzmetal) coronary
spasm

 Unstable Angina ( Pre-infarction angina) plaque rupture

 dissection,
hemorrhage
non-Q wave MI
(subendocardial or non-STEMI)
 Acute MI
Q wave MI ( transmural or thrombosis
STEMI ) total occlusion

sudden death syndrome

acute pulmonary edema ( Killip’s class III)
cardiogenic shock ( Killips class IV)
cardiac rupture
 Chest pain
EKG

normal ST depression ST elevation

Non-cardiac transient persistent transient persistent

or angina Subendocardial Variant or Acute MI
infarction Prinzmetal
Angina

Subacute

old
 Risk Factors For CAD
Major
Hyperlipidemia
Hypertension
Diabetes mellitus
Cigarette smoking
Others
Obesity Elevated c- reactive
protein
Physical inactivity Hypothyroidism
Positive Family history Acromegaly
Hypertriglyceridemia Homocystinemia
 Differential Diagnosis of Acute
MI
 Does the patient with chest pain need to be in the hospital?
Patients with unstable angina and acute MI need to be in the
hospital.

Hospitalization Outpatient work-up

 Pulmonary emboli Acute pericarditis
 Aortic dissection HOCM
 Acute myopericarditis Prolapse of MV
with arrhythmia Costochondritis ( Tietze’s
syndrome)
 Serious trauma Reflux esophagitis /
Esophageal spasm
Drug induced myocardial ischemia
Aortic stenosis
Mild chest trauma

Are the diagnostic test you are contemplating available on an

outpatient basis?
 Diagnostics
Chronic stable angina
EKG
Chest x-ray
Exercise testing with or without
myocardial perfusion scan
Lipid chemistry panel
Echocardiogram for those with
heart
murmur
 Diagnostics
Unstable Angina
• Above test except for exercise
testing
• Cardiac enzymes
CPK isoenzymes
Troponin I
Persantine technitium or thallium
scans
Coronary angiogram
 Diagnostics
 Acute myocardial infarction
EKG
Chest x-ray
Cardiac enzymes
CPK isoenzymnes
Troponin I
Coronary angiogram if acute
intervention is
planned
Chest CT scan to exclude aortic
dissection if
suspected.
 Risk stratification of CAD
Common denominators of patients at
high risk for myocardial infarction
and sudden death
2. Significant multivessel coronary
artery disease

4. Impaired left ventricular function

 Risk Stratification of CAD
History
High Risk Low Risk
3. Patients with carotid absence
artery disease and
peripheral vascular
disease
7. Exertional angina NYHA
class III
9. Prior MI
 Risk Stratification of CAD
Diagnostics
High Risk Low Risk
Treadmill Findings
 2 mm of ST depression Normal
at low level of exercise
 ST segment elevation < 2mm of ST
 Ventricular tachycardia depression at
high level of
exercise
Myocardial Perfusion scan
 Multiple perfusion defects
 Risk Stratification of CAD
Continued
Diagnostics
High Risk Low Risk
Echocardiography
EF < 50% EF > 50%
Wall motion Normal wall motions
abnormalities
Radionuclide Left
ventriculography Normal wall motion
Wall motion
abnormalities
Coronary arteriogram Single vessel disease and
Significant multivessel normal EF except for LAD
disease
and EF < 50%
 Treatment of Chronic Stable
Angina
I. Risk factors modification

III. Medical Rx
A. Nitrites
1. Sublingual nitro – 0.2- 0.6 mg.
2. Nitro spray
3. Oral
a. Isosorbide dinitrate 5-20 mg q 4hrs
off 8 hours
b. Isosorbide mononitrate 20 mg BID
7 hours apart
4. Nitroglycerin ointment ½ inch – 2 inch q 6hrs off
at night
5. Nitro patch 0.1 -0.6 mg / hour _ off at night
 Treatment of chronic stable
angina
 Beta blockers preferably cardioselective
Any of the following:
a. Metoprolol 25-50mg BID to 400 MG daily
b. Atenolol 25 – 100 mg daily
c. Acebutalol 200 mg up to 1200 mg
( ISA activity)
d. Pindolol 5 mg – 40 mg BID
e. Betaxolol 5 mg to 40 mg daily
f. Bisoprolol 5- 20 mg daily

K. Calcium Channel blockers - available in sustained

release form
a. Diltiazem_ 30 mg TID up to 360 mg / day
b. Verapamil _ 80 mg TID : start at 40 mg when EF is low
c. Bipridil _ 200- 400 mg.: watch for QT prolongation

d. Anti-platelet drugs_ Aspirin or clopidogrel

 Therapy in Unstable Angina
1. Supportive Rx
a) mild sedation
b) oxygen for hypoxemia
4. IV nitroglycerin
5. IV Heparin ( UHF) or LMWH
6. Anti-platelet Rx
a) ASA
b) Abicisimab 0.25 mg/ kg bolus then
0.125 mg / kg for 12 hours
10. Betablockers
11. Anti-arrhythmic therapy for A-fib, SVT and V-
tach
which may include DC cardioversion
7. Followed by diagnostic work up for risk
 Invasive techniques
Percutaneous Interventions
 Balloon angioplasty (PTCA)
 Coronary stent
 Atherectomy
 Lasers
Coronary artery bypass surgery
A. Thoracotomy
 Saphenous vein grapfts
 Internal mammary artery graft
 Other arterial conduits
B. Closed angioscopically guided bypass surgery
 Acute MI
I. Window of opportunity:
A. Thrombolytic Rx _ 6 hours
Any of the following:
1. TPA 100 mg IV in 3 divided doses_ 15 mg IV
bolus,
then 50 mg over 30 mins. , then 35 mg over 1
hour
2. Reptelase 10 units IV bolus, then 10 units in ½
hour
3. Tenecteplase 40 mg IV bolus single dose
4. IV streptokinase drip

B. Primary PTCA or PCI _ 4 hours

Maximum benefit is obtained when performed within 1
hour of
chest pain
 Acute MI
I. Medical therapy like unstable
angina
II. Ace- inhibitors for ventricular
remodeling and CHF

IV. Hemodynamic monitoring

VI. Treatment of complications such

as arrhythmias
 Complications of acute MI and
therapy
A. Hypotension _ IV inotropic agents: Dobutamine, Dopamine,
Amrinone
B. CHF _ IV Furosemide
C. Bradycardia _ atropine or temporary pacemaker
D. Second and third degree AV block_ temporary pacemaker
E. Acute pulmonary edema _ assisted ventilation and IV
furosemide
F. Cardiogenic shock _ intra-aortic balloon pump
G. RV infarction _ IV fluids hydration
H. Acute pericarditis / Dressler’s syndrome _ NSAID / Prednisone
I. Ventricular aneurysm and systemic embolization _ IV Heparin
followed by Coumadin

K. Rupture papillary muscle acute MR

L. Acute ventricular septal defect (VSD)
M. Cardiac rupture